We investigated the influence of age at Fontan completion on the exercise capacity of patients who underwent a Fontan operation. Our study demonstrated that age at the time of the Fontan operation ...significantly affects the peak oxygen consumption at mid-term follow up and that exercise capacity is superior in patients who have undergone Fontan completion at an earlier age. These findings provide support for recommendations to perform Fontan completion procedures relatively early.
Hypothermic cardiopulmonary bypass with circulatory arrest is an important adjunct for operations on the distal aortic arch, the descending thoracic, and the thoracoabdominal aorta. The safety and ...efficacy of this technique when compared with other adjuncts (ie, simple aortic clamping, partial cardiopulmonary bypass, regional hypothermia) is not clearly established.
One hundred and ninety-two patients (age range, 20 to 83 years) with descending thoracic or thoracoabdominal aortic disease had resection and graft replacement of the involved aortic segments using hypothermic cardiopulmonary bypass and intervals of circulatory arrest (mean, 38 minutes). The technique was used when the location and severity of disease precluded placement of clamps on the proximal aorta (31 patients) or (in 161 patients) when extensive thoracic (47) or thoracoabdominal (114) aortic disease was present, and the risk for development of spinal cord ischemic injury was judged to be increased. Lower intercostal and lumbar arteries were attached separately to the aortic graft in 101 of the 161 patients (63%) who had extensive aortic replacement. No other adjuncts for spinal cord protection were used.
The 30-day mortality was 6.8% (13 patients). It was 40% (8 of 20) for patients having emergent operations (acute aortic dissection or rupture) and 2.9% (5 of 172) for all others (
p < 0.001). The 90-day mortality was 12.5% (24 patients). Paraplegia occurred in 4 and paraparesis in 1 (full recovery) of the 186 operative survivors whose lower limb function could be assessed postoperatively (2.7%). Among the 109 survivors with thoracoabdominal aortic disease, early paraplegia occurred in 1 of 36 with Crawford extent I, 0 of 42 with extent II, and 2 of 31 with extent III disease. One patient (extent II) developed paraplegia on the 9th postoperative day after a hypotensive episode. None of the 47 patients with aortic dissection developed paralysis. Among the 186 operative survivors, renal dialysis was required in 4 patients (2.2%), prolonged inotropic support in 18 (10%), reoperation for bleeding in 9 (5%), mechanical ventilation (≥ 48 hours) in 64 (34%), and tracheostomy in 17 (9%). Four patients (2%) sustained a stroke.
Hypothermic cardiopulmonary bypass with circulatory arrest provides safe and substantial protection against paralysis and renal, cardiac, and visceral organ system failure that equals or exceeds that of other currently used techniques but without the need of other adjuncts.
Background. Hypothermic cardiopulmonary bypass with circulatory arrest is an important adjunct for operations on the distal aortic arch and the descending thoracic and thoracoabdominal aorta. Its ...safety and efficacy compared with other techniques (eg, simple aortic clamping, partial cardiopulmonary bypass, and regional hypothermia) are not clearly established.
Methods. One hundred sixty-one patients (ranging from 20 to 83 years old) with descending thoracic or thoracoabdominal aortic disease had resection and graft replacement of the involved aortic segments using hypothermic cardiopulmonary bypass usually with intervals of circulatory arrest (mean interval, 38 minutes).
Results. The 30-day mortality rate was 6.2% (10 patients). It was 41% (7 of 17) for patients having emergent operations (rupture or acute dissection) and 2.1% (3 of 144) for all other patients (
p < 0.001). The 90-day mortality rate was 11.8% (19 patients). Paraplegia occurred in 4 and paraparesis in 1 of the 156 operative survivors whose lower limb function could be assessed postoperatively (3.2%). Among the 91 survivors with thoracoabdominal aortic disease, early paraplegia occurred in 1 of 33 patients with Crawford type I disease, 0 of 34 with type II disease, and 2 of 24 with type III disease. One patient (type II disease) had development of paraplegia on the tenth postoperative day. None of the 50 patients with aortic dissection experienced paralysis. Renal dialysis was required in 4 (2.5%) of the 157 operative survivors, prolonged inotropic support (> 48 hours) in 17 (11%), reoperation for bleeding in 8 (5%), mechanical ventilation (> 48 hours) in 31 (20%), and tracheostomy in 13 (8%). Three patients (1.9%) sustained a stroke.
Conclusions. Hypothermic cardiopulmonary bypass provides safe and substantial protection against paralysis and renal, cardiac, and visceral organ system failure that equals or exceeds that of other currently used techniques but without the need of other adjuncts.
Background Sympathetic innervation exerts marked effects on vascular smooth muscle cells, including a short-term homeostatic (vasoconstrictor) and a direct trophic action promoting differentiation. ...However, the role of sympathetic nervous system in long-term structural and functional modulation of the aortic wall is yet undefined. Methods Six Landrace pigs underwent bilateral thoracic sympathectomy from the stellate to T8 ganglion, whereas 10 pigs underwent sham operation. Animals were sacrificed 3 mo postoperatively. Histometrical examination was performed on specimens from the thoracic (TA) and abdominal aorta (AA) utilizing an image-processing system. A uniaxial tensile tester was utilized for biomechanical evaluation; parameters of extensibility, strength, and stiffness of aortic tissue were calculated. Results Structural aortic remodeling of sympathectomized animals was observed, including increased inner aortic diameter in TA (15.3 ± 0.4 versus 10.4 ± 0.2 mm, P < 0.001) and AA (6.7 ± 0.3 versus 5.3 ± 0.2 mm, P = 0.002), and increased wall thickness in TA (2.0 ± 0.1 versus 1.6 ± 0.1 mm, P < 0.001) but not AA. Microscopic image analysis revealed increased elastin (TA: 50.1 ± 1.1 versus 29.7% ± 0.6%, P < 0.001; AA: 20.4 ± 2.1 versus 16.3% ± 0.6%, P = 0.03) and collagen density (only in TA: 22.0 ± 0.9 versus 15.4% ± 0.5%, P < 0.001), and decreased smooth muscle density (TA: 27.6 ± 1.3 versus 54.9% ± 0.7%, P < 0.001; AA: 57.2 ± 1.5 versus 63.4% ± 0.8%, P < 0.001). Sophisticated biomechanical analysis demonstrated that following sympathectomy, TA was equally extensible but manifested augmented strength (1344 ± 73 versus 1071 ± 52 kPa, P = 0.004) and stiffness (6738 ± 478 versus 5026 ± 273 kPa, P = 0.003), in accordance with extracellular matrix protein accumulation in that region. Differences in the AA were non-significant. Conclusions Chronic thoracic sympathetic denervation causes significant structural and biomechanical remodeling of the thoracic aorta. Possible clinical implications for patients undergoing thoracic sympathectomy or chronically treated with sympathetic blockers require further investigation.
Stroke after coronary artery bypass grafting (CABG) is an infrequent, yet devastating complication with increased morbidity and mortality. We sought to determine risk factors for early ...(intraoperatively to 24 hours) and delayed (>24 hours to discharge) stroke and to identify their impact on long-term mortality after CABG. We studied 4,140 consecutive patients who underwent isolated CABG from 1992 to 2003. Long-term survival data (mean follow-up 7.4 years) were obtained from the National Death Index. Independent predictors for stroke and in-hospital mortality were determined by multivariate logistic regression analysis including all available preoperative, intraoperative, and postoperative risk factors. Independent predictors for long-term mortality were determined by multivariate Cox regression analysis. One hundred two patients (2.5%) developed early stroke and 36 patients (0.9%) delayed stroke. Independent predictors for early stroke were age, recent myocardial infarction, smoking, femoral vascular disease, body mass index, reoperation for bleeding, postoperative sepsis and/or endocarditis, and respiratory failure, whereas those for delayed stroke were female gender, white race, preoperative renal failure, respiratory failure, and postoperative renal failure. Early stroke was an independent predictor for in-hospital (odds ratio 3.49, 95% confidence interval CI 1.56 to 7.80, p = 0.002) and long-term (hazard ratio 1.70, 95% CI 1.30 to 2.21, p <0.001) mortalities. Delayed stroke was not an independent predictor for in-hospital (odds ratio 0.90, 95% CI 0.23 to 3.51, p = 0.878) or long-term (hazard ratio 0.66, 95% CI 0.38 to 1.17, p = 0.156) mortality. In conclusion, risk factors for early in-hospital stroke differ from those of delayed in-hospital stroke after CABG. Early stroke is an independent predictor for in-hospital and long-term mortalities, suggesting the need for a more frequent follow-up and appropriate pharmacologic therapy after discharge.
Aberrant right subclavian artery is the most common brachiocephalic artery congenital abnormality and may result in dysphagia from external compression by the aberrant artery on the esophagus. Repair ...of this anatomic variant can be performed by both open and hybrid endovascular techniques. This case illustrates a complication of a hybrid repair resulting in proximal migration of a vascular occlusion plug, presenting as recurrent dysphagia and need for open surgical extraction of the plug.
The long-term mortality of coronary artery bypass grafting in women in not certain. The purpose of this study was to determine and compare risk factors for long-term mortality in women and men ...undergoing coronary artery bypass grafting.
Between 1992 and 2002, 3760 consecutive patients (2598 men and 1162 women) underwent isolated coronary artery bypass grafting. Long-term survival data were obtained from the National Death Index (mean follow-up, 5.1 ± 3.2 years). Multivariable Cox regression analysis was performed, including 64 preoperative, intraoperative, and postoperative factors separately in women and men.
There were no differences in in-hospital mortality (2.7% in men vs 2.9% in women,
P = .639) and 5-year survival (82.0% ± 0.8% in men vs 81.1% ± 1.3% in women,
P = .293). After adjustment for all independent predictors of long-term mortality, female sex was an independent predictor of improved 5-year survival (hazard ratio, 0.82; 95% confidence interval, 0.71-0.96;
P = .014). Twenty-one independent predictors for long-term mortality were determined in men, whereas only 12 were determined in women. There were 9 common risk factors (age, ejection fraction, diabetes mellitus, ≥2 arterial grafts, postoperative myocardial infarction, deep sternal wound infection, sepsis and/or endocarditis, gastrointestinal complications, and respiratory failure); however, their weights were different between women and men. Malignant ventricular arrhythmias, calcified aorta, and preoperative renal failure were independent predictors only in women. Emergency operation, previous cardiac operation, peripheral vascular disease, left ventricular hypertrophy, current and past congestive heart failure, chronic obstructive pulmonary disease, body mass index of greater than 29, preoperative dialysis, thrombolysis within 7 days before coronary artery bypass grafting, intraoperative stroke, and postoperative renal failure were independent predictors only in men.
Despite equality between sexes in early outcome and superiority of female sex in long-term survival, there were 3 independent predictors for long-term mortality after coronary artery bypass grafting unique for women compared with 12 for men. Clinical decision making and follow-up should not be influenced by stereotypes but by specific findings.
Single-stage extensive replacement of the thoracic aorta: The arch-first technique Rokkas, Chris K.; Kouchoukos, Nicholas T.
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
1999, 19990101, 1999-Jan, 1999-01-00, Letnik:
117, Številka:
1
Journal Article
Recenzirano
Odprti dostop
Background: Single-stage extensive replacement of the thoracic aorta usually involves a period of circulatory arrest with performance of the graft–to–lower descending thoracic aorta anastomosis ...before performing the anastomosis to the arch vessels. To minimize the period of brain ischemia and reduce the potential for neurologic injury, we developed an alternative technique.
Methods: In 6 patients with extensive aneurysms involving the entire thoracic aorta, exposure was obtained via a bilateral thoracotomy in the anterior fourth intercostal space with transverse sternotomy. A 10-mm graft was anastomosed to the aortic graft, opposite the site of the planned anastomosis to the arch vessels. During a single period of circulatory arrest (34-46 minutes), the aortic graft was attached to a cuff of aorta containing the arch vessels. The graft was then clamped on either side, and the arch was perfused with cold blood for 20 to 36 minutes. After the distal aortic anastomosis was completed, antegrade perfusion was established via the 10-mm graft. The proximal aortic anastomosis was performed last.
Results: No patient sustained a permanent neurologic deficit. All 6 patients were discharged from the hospital.
Conclusions: The “arch-first” technique, combined with a bilateral transverse thoracotomy, allows expeditious replacement of the thoracic aorta with an acceptable interval of hypothermic circulatory arrest and minimizes the risk of retrograde atheroembolism by establishing antegrade perfusion. (J Thorac Cardiovasc Surg 1999; 117:99-105)
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